Federal Agency Needed to Oversee DSM?

Federal Agency Needed to Oversee DSM?

May 17th, 2012 // 1:33 pm @

Last week, the American Psychiatric Association unexpectedly backed down from two controversial proposals that would have increased the number of people who could have been diagnosed with psychotic or depressive disorders. The change meant that attenuated psychosis syndrome and mixed anxiety depressive disorder will not be listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, to be published next year.

The move was greeted with applause by critics who more often accuse the organization of wantonly adding to the list of psychiatric diagnoses that may greatly increase the number of people considered mentally ill and, therefore, eligible for psychiatric and medical treatment. The DSM, which is known as the Bible of psychiatry, is officially a reference tool, although its outsized influence stokes concerns that many psychiatrists rely too heavily on its diagnoses for guidance.

The DSM “has become the arbiter of who is ill and who is not, and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services,” Allen Frances, a former psychiatry department chair at Duke University School of Medicine who led the DSM-4 task force, wrote in The New York Times. “DSM drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.”

Assembling the upcoming DSM-V has, meanwhile, spawned enormous controversy. For instance, the definition of addiction is being revised to include gambling and may also introduce a more general diagnosis called “behavioral addiction — not otherwise specified.” The APA maintains such moves can save health care dollars down the road, but critics say resources may be used unnecessarily to treat substance abusers who are classified as addicts.

There has also been debate about Premenstrual Dysphoric Disorder, or PMDD, and whether the affliction should be updated as a full-blown problem alongside the likes of Major Depressive Disorder or remain a diagnosis in need of further study. The head of the APA task force, which will make a recommendation, insists PMDD is a legitimate health problem and evidence exists to warrant a diagnosis (read more here).

A backdrop to the DSM-V controversy are ties between members of the various APA working groups and drugmakers, which would benefit if new diagnoses are listed or definitions expanded in ways that more medications would be prescribed. A recent paper in PLoS Medicine noted that 69 percent of the DSM-5 task force members have ties to drugmakers, which is up from 57 percent of the DSM-IV task force members (see here).

Frances disagrees. “Many critics assume, unfairly, that DSM-V is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders, he wrote. “Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.”

This point is likely to remain a debate within a debate. Nonetheless, the wider issue remains in play. And Frances proposes that a federal agency ought to assume the job of developing the DSM, although he believes a new organization would be required, one that could be housed in the US Department of Health and Human Services, if not the Institute of Medicine or the World Health Organization. An equivalent of the FDA is needed to “mind the store,” as he puts it.

This may raise a different set of objections, of course. To what extent, for instance, should a federal agency delve deeply into determining diagnoses and definitions? On the other hand, perhaps this would remove the concerns over self-interest and conflict that have tainted the process.

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